|Year : 1975 | Volume
| Issue : 1 | Page : 32-35
Precancerous epithelioma of the limbus
NN Sood, Y Dayal, SG Nag, RC Gupta
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
N N Sood
Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All-India Institute of Medical Sciences, New Delhi-110016
|How to cite this article:|
Sood N N, Dayal Y, Nag S G, Gupta R C. Precancerous epithelioma of the limbus. Indian J Ophthalmol 1975;23:32-5
|How to cite this URL:|
Sood N N, Dayal Y, Nag S G, Gupta R C. Precancerous epithelioma of the limbus. Indian J Ophthalmol [serial online] 1975 [cited 2013 May 24];23:32-5. Available from: http://www.ijo.in/text.asp?1975/23/1/32/31333
Epithelial tumours of the limbus have caused considerable controversy and confusion in their terminology and classification. Apart from being diagnostic problems as a result, 40% of such cases undergo malignant change into invasive squamous cell carcinoma . This makes it imperative to excise these lesions in toto.
We recently came across two cases which clinically resembled Bowen's disease or intraepithelial epitheliorna but showed inconclusive changes of intraepithelial epithelioma on histopathology. This emphasizes the problems one faces when a growth presents at the limbus.
| Case Reports|| |
Case-1 : K.K.B., a 64 year old male, came with complaints of localised reddish swelling on the temporal side of the limbus right eye for the last 25 days and constant irritation and redness of the eye for the same duration. The swelling was noticed to have increased in size and was also found to be progressively encroaching on the cornea. He was a known diabetic for 10-15 years and was controlled with oral hypoglycaemic drugs.
Past history revealed sudden diminution of vision in the right eye with flashes of light and metamorphopsia after looking at a solar eclipse. He was using glasses for the past 20 years. A yellowish red swelling was observed at the same site in the same eye about a year ago which was excised elsewhere. Postoperative period was uneventful. The excised swelling was not subjected to histopathological examination.
Examination of the right eye showed an almost circular, fleshy swelling about 7 mm. x 7 mm. extending from 6.30 to 9 O'clock position at the limbus and on either side of it. Its surface was smooth, raised from the limbus and blood vessels were seen around the swelling as well as over it. The swelling was fixed to the sclera. The cornea was infiltrated for about 2.3 mm. within the limbus from 4 O'clock to 10.30 O'clock position [Figure - 1]. The swelling was non-tender. Slit lamp revealed infiltration involving only the epithelium and Bowman's membrane at places. Superficial as well as deep vascularization was seen in the proximity of the growth.
Rest of examinations revealed no abnormality except for early grade diabetic retinopathy both eyes and a macular burn in right eye.
The growth was excised carefully in toto with a wide excision. It was adherent to the sclera at 8 O'clock position, 8 mm. from the limbus. The defect in the sclera was covered by a hood flap from the conjunctiva in the lower part.
The case seen 7 months after excision showed only a faint nebular opacity in the cornea. There was no evidence of recurrence and vision was 6/9 (corrected) [Figure - 2].
Gross examination of the specimen revealed a translucent pearly white mass, measuring 5 mm. x 4 mm. x 8.5 mm. Surface showed multiple tiny vessels.
Histologically, the tissue comprised a part of cornea and part of conjunctiva. There was a thickening and marked hyperplasia of the epithelium [Figure - 3]. Cells in the middle third and lower third showed some loss of polarity and marginal increase in mitotic activity. However, no dyskeratosis was seen. The basement membrane was intact. Superficial stroma showed infiltration by chronic inflammatory cells (plasma cells and lymphocytes) [Figure - 4] Features were suggestive of leukoplakia with changes of dysplasia.
Case-2: B.V.M.R., a 43 year old male patient, clerk by profession, presented with the complaints of a swelling near the inner part of black of his right eye of five years duration which had been rapidly increasing for the past one year. He also gave the history of recurrent attacks of redness in that eye. Nothing significant was found in the past and family histories. General physical and systemic examinations revealed the patient to be perfectly alright and in a good general health.
Vision in both the eyes was 6!5. The eye lids and drainage system were normal and the eye balls were orthophoric. There was a fleshy, oval swelling on the bulbar conjunctiva, limbus and cornea in the inner intermarginal zone. The swelling measured 10 mms. x 6 mms. and it extended over to the cornea for 2 mms. It was a pinkish swelling with a central pigmented area of 2 x 2 mm. size. Prominent vessels were seei around and over the swelling [Figure - 5]. It was slightly raised from the surface and fixed to the underlying structures. Cornea showed infiltration for about one millimeter. The angle of anterior chamber was open and showed no detectable abnormality on gonioscopy. Rest of the anterior segment was normal. Direct and indirect ophthalmoscopy and Goldman's three mirror examination revealed no abnormality of the posterior segment. Intraocular tension was 17.:, mm. Hg. and 14.6 mm. Hg., Schiotz, in right and left eye respectively.
A wide excision of the growth was done under local anaesthesia. The growth was found to be adherent to the sclera as well as cornea. The defect was covered with conjunctival hood flap. The postoperative period was uneventful. There was no recurrence when seen five months after the operation and vision in both eyes had remained 6/5.
Gross examination of the specimen revealed a small pinkish fleshy mass with pigmentation in the centre measuring 1 mm. x 3 mm. Histopathology revealed the tissue to be partly cornea and partly conjunctiva. There was marked thickening and hyperplasia of the epithelium [Figure - 6]. There is evidence of some maturation with hyperkeratosis in superficial layers. The rest of the epithelium shows some degree of loss of polarity of cells and increased mitotic activity [Figure - 7] arrow. No dyskeratosis is seen. Cells reveal mild degree of pleomorphism and hyperchromatism. Basement membrane is intact. The features are highly suggestive but inconclusive of intra-epithelial epithelioma or Bowen's disease.
| Discussion|| |
Obviously a frank squamous cell carcinoma does not spring forth full blown from the conjunctiva but is preceded by a period of gradual thickening and transition in the limbal epithelium. The overall effect is a change to more skin like structure referred by some as epidermalization. The transitional area is marked by the presence of poikilocytosis  . Similar changes observed by others have been termed as tyloma. Keratosis  , Bowen's disease  , carcinoma-in-situ' and leukoplakia.
In view of similar clinical appearance and behaviour of various types of lesions, Winter and Kleh  after, an analysis of 25 cases and their comparison with the data of another 50 carefully documented cases, stated that it would seem futile to categorize them in this way and suggested an all inclusive term of precancerous epithelioma because these are tumours of the epithelium and precancerous because they have not yet invaded the stroma.
In the above mentioned cases, the progressive growth, the infiltration into the epithelium and Bowmen's membrane of the cornea, vascularization (superficial and deep), fixation to underlying sclera and history of recurrence in the first case all pointed to such a diagnosis. A careful wide dissection performed as a result, revealed inconclusive evidence of intraepithelial epithelioma on histopathological examination.
Such an eventuality in our cases, showing all distinct features of an intraepithelial epithelioma or Bowen's disease and yet not being confirmed on histopathological examination only subserves to emphasize the futility in categorizing these lesions. We, therefore, favour the terminology adopted by Winter and Kleh  of precancerous epithelioma of the limbus.
| Summary|| |
Two cases of precancerous epithelioma of the limbus are reported. The difficulties in the diagnosis and terminology of the condition are discussed.
| References|| |
|1.||Ash, J. E. and Wilder, H. C.. 1942, Amer. J. Ophthal., 25, 926. |
|2.||Ballantyne, A. J. and Michaelson, I. C., Trans. Ophthal.. Soc. U. K. 1947,;67, 59. |
|3.||Lugossy, G., Amer. J. Ophthal 1956., 42, 112. |
|4.||McGavic, J. S., Amer. J. Ophthal. 1942, 25, 167. |
|5.||Mohr and Schein, cited by Nicolls (1939). |
|6.||Nicolls, J. V. Arch. Ophtiral. 1939, 22, 370. |
|7.||Reeh, M. J., published by C. C. Thomas and Co. p. 73, 1963. |
|8.||Winter F. C. and Kleh, T. R., Arch. Ophthal. 1960, 64, 208. |
[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7]